- Email: [email protected]
Rural Primary Care Centers as a Source of Information About Organ Donation
Rural Primary Care Centers as a Source of Information About Organ Donation C. Conesa, A. Rı´os, P. Ramı´rez, J. Sánchez, E. Sánchez, O.M. Fernández, M.M. Rodrı´guez, F. Ramos, and P. Parrilla ABSTRACT Introduction. Primary care is an important way of promoting health in the community, and this includes organ donation. In rural areas, this way of promoting health acquires special importance. Our objective was to analyze attitudes toward organ donation among primary care workers in rural health centers to assess their importance in circulating information about donation. Materials and methods. A random sample, stratified according to job category among the primary care staff (n ⫽ 160), of workers in rural areas in our autonomous community (population ⬍ 10,000 inhabitants), evaluated attitudes toward donation using a questionnaire validated in our geographic area. To distribute the questionnaire it was necessary to contact the following in each health center: the coordinating physician, the nursing coordinator, and an administrative worker. Results. Of those questioned, 78% (n ⫽ 124) were in favor of donation, as opposed to 22% (n ⫽ 36) who are against it or undecided. As for the job category, physicians and nurses showed a more favorable attitude than nonhealth workers (90% and 80% vs 61%; P ⫽ .000). The psychosocial variables that were related to such an attitude were knowledge of the concept of brain death (P ⫽ .013) and lack of fear of manipulation of the deceased person (P ⫽ .002). Regarding information about organ donation and transplantation, 54% (n ⫽ 86) reported having been provided favorable information, with up to a quarter of the physicians considering other programs to be of greater interest for primary care than organ donation and transplantation. Conclusion. Attitudes toward organ donation were favorable among a high percentage of primary care workers in rural centers; more than 50% have circulated favorable information on the subject. However, there is a high percentage with a negative or undecided attitude, especially among nonhealth workers, which should be reversed with promotional activities at the level of the health center.
T
HE DECISION TO DONATE is a process prior to transplantation that is strongly affected by psychosocial factors.1,2 The general opinion of Spanish people toward organ donation is positive. However, at crucial times in the request for organ donation, the initial favorable attitude only reaches 75% to 80% of possible donors.1,3 In order to reduce this deficiency it is necessary to work within society to provide adequate information encouraging favorable opinions toward donation. Primary care (PC) represents the first level of contact of the population with the health service. This access of the general population to PC might constitute an effective means to promote organ donation.4 – 6 Thus, favorable information given by health professionals about organ
donation and transplantation has a greater positive effect on opinions toward this subject than that provided by other sources.7–9 From the Coordinación Regional de Trasplantes de la Comunidad Autónoma de Murcia (C.C., A.R., P.R.), Consejerı´a de Sanidad, Ronda de Levante, Murcia, Spain; Centro de Salud de Fortuna Gerencia de Atención Primaria de Murcia Area, Fortuna, (C.C.), Murcia, Spain; Departamento de Cirugı´a (A.R., P.R., O.M.F., M.M.R.), Hospital Universitario Virgen de la Arrixaca, El Palmar Murcia, Spain; and Asociación de Ayuda al Enfermo Renal (ADAER) (J.S., E.S., F.R., P.P.), Murcia. Address reprint requests to Dr Antonio Rı´os Zambudio, Avenida de la Libertad no. 208, Casillas 30007, Murcia, Espanña. E-mail: [email protected]
© 2005 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/05/$–see front matter doi:10.1016/j.transproceed.2005.08.060
Transplantation Proceedings, 37, 3609 –3613 (2005)
3609
3610
The objectives of this study were to determine (1) the attitudes of different job categories of primary health care in rural centers of our autonomous community toward deceased organ donation and (2) the importance these attitudes in circulating information about donation. MATERIALS AND METHODS Population In our autonomous community there are 23 primary care health centers in geographically rural areas (towns or municipalities of ⬍10,000 inhabitants). The sample has been stratified according to geographical location (the six community health areas) and job category (physicians, nurses, and nonhealth workers). We chose 12 health centers and 160 professionals (58 physicians, 51 nurses, and 51 nonhealth professionals).
Opinion Survey and Variables Opinions were evaluated using 30 multiple choice questions, validated in our geographic area10 between October 2002 and October 2003. For its distribution, contact was made in each selected center with the physician coordinator, the nursing coordinator, and an administrative member of staff, who were educated about the study and made responsible for distributing the questionnaire. The self-administered questionnaire was completed anonymously. The process was coordinated by two health collaborators from the Regional Transplant Co-ordination Centre and by two workers from the Association of Kidney Transplant Patients. The variables were: (1) sociopersonal demographics (age, sex, marital status, job category); (2) knowledge about donation (prior experience with transplant organs, concept of brain death); (3) social interactions (partner’s attitude toward donation); (4) attitudes toward the body (toward cadaveric manipulation); (5) prosocial behavior (attitude toward blood donation); (6) human donation; and (7) information requested and given by these professionals on donation.
Statistics The data were analyzed using the SPSS 11.0 statistics package. Descriptive statistics compared the variables using Student t test and the chi-square test, together with an analysis of the remainders. Differences were considered to be significant when levels of P ⬍ .05.
RESULTS Attitude Toward Organ Transplant and Donation
Among the 160 subjects, 78% (n ⫽ 124) were prepared to donate their organs, as opposed to 22% (n ⫽ 36) who would not donate or have doubts about donating. On analyzing the various psychosocial variables, no differences were seen in attitudes toward donation, according to age, sex, or marital status. However, with respect to job category, a more positive attitude was observed among physicians and nurses than nonhealth workers (90% and 80% vs 61%, P ⫽ .000; Table 1). Prior experience with organ donation and/or transplantation (knowing transplant patients, prior donation in the family, etc) was a factor that did not affect attitudes toward donation; neither did taking part in prosocial activities. Regarding knowledge of the concept of brain death, it was
CONESA, RÍOS, RAMÍREZ ET AL Table 1. Variables That Influence Opinion Toward Organ Transplant and Donation of Staff in Primary Care Health Centers in Our Geographical Area
Variable
Age (39 ⫾ 8 years) Sex Male (n ⫽ 66) Female (n ⫽ 84) Does not Know (n ⫽ 10) Marital status Single (n ⫽ 48) Married (n ⫽ 97) Widowed (n ⫽ 2) Separated/divorced (n ⫽ 5) Does not know (n ⫽ 8) Job category Doctor (n ⫽ 58) Nurse (n ⫽ 51) Nonhealth (n ⫽ 51) Prior experience of donation No (n ⫽ 91) Yes (n ⫽ 69) Prosocial activities No (n ⫽ 15) Yes (n ⫽ 132) Does not know (n ⫽ 13) Knows concept of brain death No (n ⫽ 4) Yes (n ⫽ 103) Doubts (n ⫽ 53) Incineration No (n ⫽ 89) Yes (n ⫽ 71) Concerned about mutilation No (n ⫽ 146) Yes (n ⫽ 8) Does not know (n ⫽ 6) Partner’s opinion Favourable (n ⫽ 104) Unfavourable (n ⫽ 4) Opinion not known (n ⫽ 29) No partner (n ⫽ 17) Does not know (n ⫽ 6)
In Favor of donation (n ⫽ 124)
Against donation (n ⫽ 36)
39 ⫾ 8
37 ⫾ 7
.288
55 (44%) 67 (54%) 2
11 (30%) 17 (47%) 8
.577
39 (31%) 79 (64%) 2 (2%) 4 (3%) 0
9 (25%) 18 (50%) 0 (0%) 1 (3%) 8
52 (42%) 41 (33%) 31 (25%)
6 (16%) 10 (28%) 20 (56%)
.000
68 (55%) 56 (45%)
23 (64%) 13 (36%)
.334
12 (72%) 108 (25%) 4
3 (50%) 24 (25%) 9
4 (3%) 86 (69%) 34 (28%)
0 (0%) 17 (47%) 19 (53%)
.013
61 (49%) 63 (51%)
28 (78%) 8 (22%)
.002
114 (92%) 6 (5%) 4
32 (89%) 2 (6%) 2
.794
87 (70%) 2 (2%) 19 (15%) 11 (9%) 5
17 (47%) 2 (6%) 10 (28%) 6 (17%) 1
.088
P
⬎.05
⬎.05
noteworthy that up to 33% (n ⫽ 53) had doubts about the concept, a group whose attitudes were less favorable than those who had an understanding of the concept (64% vs 83%; P ⫽ .013). There was a tendency toward a more positive attitude among those having a partner with a favorable opinion as opposed to those with a partner whose opinion was not favorable (84% vs 50%). Finally, those who are not against manipulation of the deceased had a more favorable attitude toward donation than those who were against such manipulation. In this way, those who favored incineration had a more favorable attitude toward deceased donation than those who did not (89% vs 68%; P ⫽ .002).
RURAL PRIMARY CARE CENTERS
3611
Fig 1. Information requested on organ donation and transplantation from primary care professionals in rural centers.
Professionals From Rural Primary Care Centers as Sources of Information on Donation
Of those surveyed 45% (n ⫽ 72) reported that they have been requested information about organ donation and transplantation by their patients or by the general population at one point in their professional career. This percentage of requests for information was greater among physicians and nurses than nonhealth professionals (51% and 54% vs 28%; P ⬍ .05; Fig 1). As for information given on the subject, 54% (n ⫽ 86) reported having given information in favor and 0.6% (n ⫽ 1) against. Those persons who have provided the least information about the subject are nonhealth workers (33% vs 65% of physicians and 65% of nurses, P ⫽ .029; Fig 2). With respect to the establishment of a program for promotion of organ donation and transplantation in the health center, 69% (n ⫽ 110) were in favor. However, 23% of the physicians (n ⫽ 13) considered that there are other programs of greater social interest that should be established first. Furthermore, 19% (n ⫽ 31) of the total surveyed were undecided about the usefulness of such a program. However, as for the establishment of an informative course about organ donation and transplantation for primary care workers, only 54% were in favor (n ⫽ 160), while 31% (n ⫽ 49) doubt its usefulness. No differences were observed according to job category. DISCUSSION
The process of obtaining organs involves the participation of many professionals at hospital as well as the extrahospital level.11 Positive or negative attitudes toward donation and transplantation among nurses, physicians, and other health professionals have a clear and overwhelming influence on
families who go through the terrible experience of a sudden death in their environment and have to decide without hesitation, in those sad moments, about organ donation. Therefore, one should not forget activities to raise awareness about donation and transplantation in hospitals and health centers. As occurs in the general public, rigorous and up-to-date information about the subject encourages more positive attitudes toward donation among health professionals.12–16 Subgroups of the Spanish population have negative attitudes toward organ donation. One subgroup is rural geographical areas1,2,14,17; not just economic level or rate of illiteracy but other factors as well have an influence.18 PC offers a series of advantages to promote organ donation as they are accessible to practically the whole population, allowing for intercorrelation of data with the spokesperson. In this way, studies in our geographical area9 showed a clear improvement in attitudes toward donation among a population informed about this subject by PC health professionals (89%) as opposed to those who received other sources of information (65%). However, it must be taken into account that the information may be positive or negative. Thus, negative information about donation circulated from the PC level has a much greater impact on the population than that circulated by other means. In health matters, professionals have a great social impact.9 In addition, a negative attitude toward donation is much more difficult to reverse as it is based on information provided by a health professional. Our study showed that in a rural area nearly 50% of PC professionals have been requested information about donation at some point, and nearly 54% of these professionals have provided information about the topic. It must be emphasized that the percentage of professionals who report giving unfavorable information is low (0.6%), which corre-
3612
CONESA, RÍOS, RAMÍREZ ET AL
Fig 2. Information provided on organ donation and transplantation by professionals in primary care centers.
sponds to one doctor. However, if we take into account the mean number of patients per physician in these areas, namely 1500 to 2500 patients/quota, the potential impact on this population could be important.9 PC also has disadvantages that make it difficult to introduce promotion of organ donation and transplantation as just another ordinary activity in daily life, as is overcrowding. There are often other health promotion programs to be developed in various centers.5,6 Thus, nearly a quarter of those surveyed recognize that there are other programs to be developed, which they considered to be of greater interest to the health of society than the one that we are dealing with here. Bidigare et al7 performed a study on PC centers, observing that the physician–patient relationship provides an excellent opportunity to improve education about donation. This brief intervention does not alter the rhythm of the consultation. However, in the rural area of our community only 78% of PC professionals had a favorable opinion toward organ donation. It would be difficult for the remaining 22%, who have a negative opinion or are undecided about the subject, to provide information which favors the subject. What is more, this situation is more pronounced among nonhealth professionals. This finding is important, as working in a health center means that the opinion of these professionals has a strong impact on the general population’s attitudes toward organ donation. It must be remembered that as health professionals it is our responsibility to promote health in general. Transplantation is the only possibility of health for many patients. Therefore we are obliged to promote and favor organ donation and transplantation because thereby we are favoring health.19 –21 In this regard, some initiatives have been developed, including the outstanding European Donor Hospital Education Program, which has achieved an im-
provement in attitude and knowledge toward organ donation.22 Currently, the rate of donation and family refusals has stabilized. It is necessary to find new means to take action in the population to improve these rates. PC may be the key piece to overcome the “ceiling” that donation has reached in our country. In light of this, training and information campaigns should be reinforced among PC workers. However, as seen in our study, not all professionals would be willing to participate in them. When analyzing factors that determine the attitudes of surveyed PC professionals toward organ donation and transplantation, various classical psychosocial factors seem to influence the attitude of these workers, especially nonhealth workers. Nonetheless, in comparison with the general population, the PC professionals clearly presented more favorable attitudes.10 Among the important factors are: knowledge of the concept of brain death and attitude toward manipulation of the deceased including incineration. However, other factors did not have an influence, such as age, prior experience with the subject, partner’s opinion, and so on. It is important to remember that transplantation has brought about important changes in society, including the concept of brain death.14 In our series, knowledge of this concept, different than what was expected given the training background of those surveyed, continues to influence attitudes toward donation. In any case, the most significant factor in this study is job category. Thus, physicians and nurses had a much more favorable attitude toward donation than nonhealth workers, which was similar to that described in our general population.10 In conclusion, attitudes toward organ donation were favorable in a high percentage of the staff at rural PC centers, where more than 50% of professionals provided favorable information about the topic. However, there was
RURAL PRIMARY CARE CENTERS
a high percentage with a negative or undecided attitude, especially among nonhealth staff, which may be reversed by promotion activities at the health center level.
REFERENCES 1. Martı´nez JM, Martı´n A, López JS: La opinión pública española ante la donación y el trasplante de órganos. Med Clin 105:401, 1995 2. Martı´nez JM, López JS, Martı´n A: Percepción social de la donación en España tras la década de los trasplantes. Nefrologı´a 21(suppl 4):45, 2001 3. Matesanz R, Miranda B: Editores. El modelo español. Coordinación y trasplantes. Grupo Aula Médica SA; 1995 4. Cuende N, Miranda B: La donación de órganos para trasplante y la Atención Primaria. Medifam 10:143, 2000 5. Conesa C, Rı´os A, Ramı´rez P: Sobre la donación de órganos para trasplantes y la Atención Primaria. Medifam 11:232, 2001 6. Rı´os Zambudio A, Conesa Bernal C, Munuera Orenes C, et al: Donación y trasplante de órganos en España: importancia del papel de la Atención Primaria. Medicina Integral 33:89, 1999 7. Bidigare SA, Ellis AR: Family physicians’ role in recruitment of organ donors. Arch Fam Med 9:601, 2000 8. Coolican MB, Swanson A: Primary health-care physicians: vital roles in organ and tissue donation. Conn Med 62:149, 1998 9. Conesa Bernal C, Rı´os Zambudio A, Ramı´rez Romero P, et al: Importancia de los profesionales de atención primaria en la educación sanitaria de la donación de órganos. Aten Primaria 34:528, 2004 10. Conesa C, Rı´os A, Ramı´rez P, et al: Psycho-social profile in favour of organ donation. Transplant Proc 35:1276, 2003
3613 11. Pearson IY, Zurynski Y: A survey of personal and professional attitudes of intensivists to organ donation and transplantation. Anesth Intens Care 23:68, 1995 12. Martı´nez JM, López JS, Martı´n A: Percepción social de la donación en España tras la década de los trasplantes. Nefrologı´a 21(suppl 4):45, 2001 13. Martı´n Gonzalez A, Martı´nez Garcı´a JM, Manrique S: Donación de órganos para trasplantes. Aspectos psicosociales, Nefrologı´a 11(suppl 1):62, 1991 14. Pérez San Gregorio MA, Domı´nguez Roldán JM, Murillo Cabezas F, et al: Factores sociales y psicológicos que influyen en la donación de órganos. Psicothema 5:241, 1993 15. Frutos MA, Blanca MJ: La conciencia social: importancia de la negativa familiar en los programas de trasplante. Rev Esp Trasp 4:338, 1995 16. Frutos MA: Percepción social de la donación en el año 2000. Nefrologı´a 21(suppl 4):41, 2001 17. Santiago C, Gómez P, Franco A, et al: Actitudes de la población ante la donación. Nefrologı´a 11(suppl 1):55, 1991 18. Conesa Bernal C, Rı´os Zambudio A, Ramı´rez Romero P, et al: Actitud hacia la donación de órganos en las áreas geográficas rurales. Salud Rural 20:37, 2003 19. Jonasson O: Obligations of the health care community in organ procurement. Transplant Proc 22:1010, 1990 20. Mann JE: Obligations of the health care community in organ procurement. Transplant Proc 22:1012, 1990 21. Riker RR, White BW: The effect of physician education on the rates of donation request and tissue donation. Transplantation 59:880, 1995 22. Singer P, Rachmani R: Improving attitude and knowledge of healthcare professionals towards organ donation in Israel: results of 12 European donor hospital education programs. Transplant Proc 29:3244, 1997
T
HE DECISION TO DONATE is a process prior to transplantation that is strongly affected by psychosocial factors.1,2 The general opinion of Spanish people toward organ donation is positive. However, at crucial times in the request for organ donation, the initial favorable attitude only reaches 75% to 80% of possible donors.1,3 In order to reduce this deficiency it is necessary to work within society to provide adequate information encouraging favorable opinions toward donation. Primary care (PC) represents the first level of contact of the population with the health service. This access of the general population to PC might constitute an effective means to promote organ donation.4 – 6 Thus, favorable information given by health professionals about organ
donation and transplantation has a greater positive effect on opinions toward this subject than that provided by other sources.7–9 From the Coordinación Regional de Trasplantes de la Comunidad Autónoma de Murcia (C.C., A.R., P.R.), Consejerı´a de Sanidad, Ronda de Levante, Murcia, Spain; Centro de Salud de Fortuna Gerencia de Atención Primaria de Murcia Area, Fortuna, (C.C.), Murcia, Spain; Departamento de Cirugı´a (A.R., P.R., O.M.F., M.M.R.), Hospital Universitario Virgen de la Arrixaca, El Palmar Murcia, Spain; and Asociación de Ayuda al Enfermo Renal (ADAER) (J.S., E.S., F.R., P.P.), Murcia. Address reprint requests to Dr Antonio Rı´os Zambudio, Avenida de la Libertad no. 208, Casillas 30007, Murcia, Espanña. E-mail: [email protected]
© 2005 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/05/$–see front matter doi:10.1016/j.transproceed.2005.08.060
Transplantation Proceedings, 37, 3609 –3613 (2005)
3609
3610
The objectives of this study were to determine (1) the attitudes of different job categories of primary health care in rural centers of our autonomous community toward deceased organ donation and (2) the importance these attitudes in circulating information about donation. MATERIALS AND METHODS Population In our autonomous community there are 23 primary care health centers in geographically rural areas (towns or municipalities of ⬍10,000 inhabitants). The sample has been stratified according to geographical location (the six community health areas) and job category (physicians, nurses, and nonhealth workers). We chose 12 health centers and 160 professionals (58 physicians, 51 nurses, and 51 nonhealth professionals).
Opinion Survey and Variables Opinions were evaluated using 30 multiple choice questions, validated in our geographic area10 between October 2002 and October 2003. For its distribution, contact was made in each selected center with the physician coordinator, the nursing coordinator, and an administrative member of staff, who were educated about the study and made responsible for distributing the questionnaire. The self-administered questionnaire was completed anonymously. The process was coordinated by two health collaborators from the Regional Transplant Co-ordination Centre and by two workers from the Association of Kidney Transplant Patients. The variables were: (1) sociopersonal demographics (age, sex, marital status, job category); (2) knowledge about donation (prior experience with transplant organs, concept of brain death); (3) social interactions (partner’s attitude toward donation); (4) attitudes toward the body (toward cadaveric manipulation); (5) prosocial behavior (attitude toward blood donation); (6) human donation; and (7) information requested and given by these professionals on donation.
Statistics The data were analyzed using the SPSS 11.0 statistics package. Descriptive statistics compared the variables using Student t test and the chi-square test, together with an analysis of the remainders. Differences were considered to be significant when levels of P ⬍ .05.
RESULTS Attitude Toward Organ Transplant and Donation
Among the 160 subjects, 78% (n ⫽ 124) were prepared to donate their organs, as opposed to 22% (n ⫽ 36) who would not donate or have doubts about donating. On analyzing the various psychosocial variables, no differences were seen in attitudes toward donation, according to age, sex, or marital status. However, with respect to job category, a more positive attitude was observed among physicians and nurses than nonhealth workers (90% and 80% vs 61%, P ⫽ .000; Table 1). Prior experience with organ donation and/or transplantation (knowing transplant patients, prior donation in the family, etc) was a factor that did not affect attitudes toward donation; neither did taking part in prosocial activities. Regarding knowledge of the concept of brain death, it was
CONESA, RÍOS, RAMÍREZ ET AL Table 1. Variables That Influence Opinion Toward Organ Transplant and Donation of Staff in Primary Care Health Centers in Our Geographical Area
Variable
Age (39 ⫾ 8 years) Sex Male (n ⫽ 66) Female (n ⫽ 84) Does not Know (n ⫽ 10) Marital status Single (n ⫽ 48) Married (n ⫽ 97) Widowed (n ⫽ 2) Separated/divorced (n ⫽ 5) Does not know (n ⫽ 8) Job category Doctor (n ⫽ 58) Nurse (n ⫽ 51) Nonhealth (n ⫽ 51) Prior experience of donation No (n ⫽ 91) Yes (n ⫽ 69) Prosocial activities No (n ⫽ 15) Yes (n ⫽ 132) Does not know (n ⫽ 13) Knows concept of brain death No (n ⫽ 4) Yes (n ⫽ 103) Doubts (n ⫽ 53) Incineration No (n ⫽ 89) Yes (n ⫽ 71) Concerned about mutilation No (n ⫽ 146) Yes (n ⫽ 8) Does not know (n ⫽ 6) Partner’s opinion Favourable (n ⫽ 104) Unfavourable (n ⫽ 4) Opinion not known (n ⫽ 29) No partner (n ⫽ 17) Does not know (n ⫽ 6)
In Favor of donation (n ⫽ 124)
Against donation (n ⫽ 36)
39 ⫾ 8
37 ⫾ 7
.288
55 (44%) 67 (54%) 2
11 (30%) 17 (47%) 8
.577
39 (31%) 79 (64%) 2 (2%) 4 (3%) 0
9 (25%) 18 (50%) 0 (0%) 1 (3%) 8
52 (42%) 41 (33%) 31 (25%)
6 (16%) 10 (28%) 20 (56%)
.000
68 (55%) 56 (45%)
23 (64%) 13 (36%)
.334
12 (72%) 108 (25%) 4
3 (50%) 24 (25%) 9
4 (3%) 86 (69%) 34 (28%)
0 (0%) 17 (47%) 19 (53%)
.013
61 (49%) 63 (51%)
28 (78%) 8 (22%)
.002
114 (92%) 6 (5%) 4
32 (89%) 2 (6%) 2
.794
87 (70%) 2 (2%) 19 (15%) 11 (9%) 5
17 (47%) 2 (6%) 10 (28%) 6 (17%) 1
.088
P
⬎.05
⬎.05
noteworthy that up to 33% (n ⫽ 53) had doubts about the concept, a group whose attitudes were less favorable than those who had an understanding of the concept (64% vs 83%; P ⫽ .013). There was a tendency toward a more positive attitude among those having a partner with a favorable opinion as opposed to those with a partner whose opinion was not favorable (84% vs 50%). Finally, those who are not against manipulation of the deceased had a more favorable attitude toward donation than those who were against such manipulation. In this way, those who favored incineration had a more favorable attitude toward deceased donation than those who did not (89% vs 68%; P ⫽ .002).
RURAL PRIMARY CARE CENTERS
3611
Fig 1. Information requested on organ donation and transplantation from primary care professionals in rural centers.
Professionals From Rural Primary Care Centers as Sources of Information on Donation
Of those surveyed 45% (n ⫽ 72) reported that they have been requested information about organ donation and transplantation by their patients or by the general population at one point in their professional career. This percentage of requests for information was greater among physicians and nurses than nonhealth professionals (51% and 54% vs 28%; P ⬍ .05; Fig 1). As for information given on the subject, 54% (n ⫽ 86) reported having given information in favor and 0.6% (n ⫽ 1) against. Those persons who have provided the least information about the subject are nonhealth workers (33% vs 65% of physicians and 65% of nurses, P ⫽ .029; Fig 2). With respect to the establishment of a program for promotion of organ donation and transplantation in the health center, 69% (n ⫽ 110) were in favor. However, 23% of the physicians (n ⫽ 13) considered that there are other programs of greater social interest that should be established first. Furthermore, 19% (n ⫽ 31) of the total surveyed were undecided about the usefulness of such a program. However, as for the establishment of an informative course about organ donation and transplantation for primary care workers, only 54% were in favor (n ⫽ 160), while 31% (n ⫽ 49) doubt its usefulness. No differences were observed according to job category. DISCUSSION
The process of obtaining organs involves the participation of many professionals at hospital as well as the extrahospital level.11 Positive or negative attitudes toward donation and transplantation among nurses, physicians, and other health professionals have a clear and overwhelming influence on
families who go through the terrible experience of a sudden death in their environment and have to decide without hesitation, in those sad moments, about organ donation. Therefore, one should not forget activities to raise awareness about donation and transplantation in hospitals and health centers. As occurs in the general public, rigorous and up-to-date information about the subject encourages more positive attitudes toward donation among health professionals.12–16 Subgroups of the Spanish population have negative attitudes toward organ donation. One subgroup is rural geographical areas1,2,14,17; not just economic level or rate of illiteracy but other factors as well have an influence.18 PC offers a series of advantages to promote organ donation as they are accessible to practically the whole population, allowing for intercorrelation of data with the spokesperson. In this way, studies in our geographical area9 showed a clear improvement in attitudes toward donation among a population informed about this subject by PC health professionals (89%) as opposed to those who received other sources of information (65%). However, it must be taken into account that the information may be positive or negative. Thus, negative information about donation circulated from the PC level has a much greater impact on the population than that circulated by other means. In health matters, professionals have a great social impact.9 In addition, a negative attitude toward donation is much more difficult to reverse as it is based on information provided by a health professional. Our study showed that in a rural area nearly 50% of PC professionals have been requested information about donation at some point, and nearly 54% of these professionals have provided information about the topic. It must be emphasized that the percentage of professionals who report giving unfavorable information is low (0.6%), which corre-
3612
CONESA, RÍOS, RAMÍREZ ET AL
Fig 2. Information provided on organ donation and transplantation by professionals in primary care centers.
sponds to one doctor. However, if we take into account the mean number of patients per physician in these areas, namely 1500 to 2500 patients/quota, the potential impact on this population could be important.9 PC also has disadvantages that make it difficult to introduce promotion of organ donation and transplantation as just another ordinary activity in daily life, as is overcrowding. There are often other health promotion programs to be developed in various centers.5,6 Thus, nearly a quarter of those surveyed recognize that there are other programs to be developed, which they considered to be of greater interest to the health of society than the one that we are dealing with here. Bidigare et al7 performed a study on PC centers, observing that the physician–patient relationship provides an excellent opportunity to improve education about donation. This brief intervention does not alter the rhythm of the consultation. However, in the rural area of our community only 78% of PC professionals had a favorable opinion toward organ donation. It would be difficult for the remaining 22%, who have a negative opinion or are undecided about the subject, to provide information which favors the subject. What is more, this situation is more pronounced among nonhealth professionals. This finding is important, as working in a health center means that the opinion of these professionals has a strong impact on the general population’s attitudes toward organ donation. It must be remembered that as health professionals it is our responsibility to promote health in general. Transplantation is the only possibility of health for many patients. Therefore we are obliged to promote and favor organ donation and transplantation because thereby we are favoring health.19 –21 In this regard, some initiatives have been developed, including the outstanding European Donor Hospital Education Program, which has achieved an im-
provement in attitude and knowledge toward organ donation.22 Currently, the rate of donation and family refusals has stabilized. It is necessary to find new means to take action in the population to improve these rates. PC may be the key piece to overcome the “ceiling” that donation has reached in our country. In light of this, training and information campaigns should be reinforced among PC workers. However, as seen in our study, not all professionals would be willing to participate in them. When analyzing factors that determine the attitudes of surveyed PC professionals toward organ donation and transplantation, various classical psychosocial factors seem to influence the attitude of these workers, especially nonhealth workers. Nonetheless, in comparison with the general population, the PC professionals clearly presented more favorable attitudes.10 Among the important factors are: knowledge of the concept of brain death and attitude toward manipulation of the deceased including incineration. However, other factors did not have an influence, such as age, prior experience with the subject, partner’s opinion, and so on. It is important to remember that transplantation has brought about important changes in society, including the concept of brain death.14 In our series, knowledge of this concept, different than what was expected given the training background of those surveyed, continues to influence attitudes toward donation. In any case, the most significant factor in this study is job category. Thus, physicians and nurses had a much more favorable attitude toward donation than nonhealth workers, which was similar to that described in our general population.10 In conclusion, attitudes toward organ donation were favorable in a high percentage of the staff at rural PC centers, where more than 50% of professionals provided favorable information about the topic. However, there was
RURAL PRIMARY CARE CENTERS
a high percentage with a negative or undecided attitude, especially among nonhealth staff, which may be reversed by promotion activities at the health center level.
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